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Editorials
Chronic Disease Management
During Ramadan
Salman Waqar, MRCGP, Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
Nazim Ghouri, MD, Institute of Cardiovascular and Medical Sciences, University of Glasgow,
Glasgow, United Kingdom;​Queen Elizabeth University Hospital, Glasgow, United Kingdom
Rania Awaad, MD, Stanford Muslim Mental Health Lab, Stanford Diversity Clinics, Department of
Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
Published online January 3, 2023.
Ramadan is the ninth month of the Islamic lunar calen-
dar and, for postpubertal Muslims, is observed with fast-
ing. Fasting for Ramadan comprises abstaining from food,
drink, and sexual intercourse during daylight hours. All
forms of medication administered orally, nasally, or rectally
are also not permitted. Those with various ailments may be
religiously exempt from continuous daily fasting if health
and safety are compromised. This editorial provides guid-
ance on chronic disease management and explores specific
ways physicians can support patients who observe Ramadan.
Risk Stratification
Patients with chronic conditions who want to fast during
Ramadan should be individually assessed to determine
whether fasting is safe. The International Diabetes Fed-
eration and the Diabetes and Ramadan International
Alliance provide a structured, traffic-light system for man-
aging diabetes mellitus during Ramadan, most recently
updated in 2021.1 This system was expanded into the Brit-
ish Islamic Medical Association’s Ramadan compendium,
which includes a wider range of chronic conditions. The
compendium incorporates expert consensus and evidence
synthesis to create a risk-stratification system that enables
patient-centered shared decision-making about Ramadan
fasting.2 Guidance from the compendium provides a com-
mon framework for counseling a patient in preparation for
Ramadan, assessing risk, and potentially tailoring existing
medical treatment.2
Patients may be categorized as low to moderate risk, with
no clear contraindications to fasting, but perhaps need-
ing general advice about aspects of fasting, including sick
day rules or ensuring adequate nutrition and fluid intake
during nonfasting hours. Patients who are high to very high
risk should be advised not to fast;​however, patients’ desire
to fast may be strong, and they may benefit from clinical
input. The British Islamic Medical Association’s Ramadan
compendium offers a risk-reduction approach but does not
replace individual clinical judgment.2
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Ramadan fasting is an individualized choice, with med-
ical exemptions and other dispensations.2 In general, daily
consecutive fasting for the entire month (from approxi-
mately March 22, 2023, to April 23, 2023) is not a binary
decision, and patients may fast intermittently if their health
permits it.3 Some may fast later in the year, when fewer
hours of daylight and an agreeable climate make fasting
easier (Table 1). Information about prior experience with
Ramadan fasting is helpful in determining how patients
TABLE 1
Alternatives to Fasting During Ramadan
Nonconsecutive Ramadan fasts
Ideally, patients at higher risk should have trial periods of
fasting before Ramadan to optimize medications and to
acclimate their bodies. If patients find daily fasting intol-
erable, they may choose to fast some days of Ramadan,
with nonfasting days of recovery in between. Missed days
could be made up by fasting before the next Ramadan,
bearing in mind the Islamic year is based on a lunar calen-
dar and is shorter by approximately 11 days.
Make-up fasts post-Ramadan
Making up fasts is common in cases of acute illness,
travel, and menstruation. Fasts are usually made up
immediately after Ramadan, but those with chronic illness
may choose to delay this to later in the year.
Fasting in winter months
Hours of daylight, and therefore the length of the Rama-
dan fast, varies considerably depending on geographical
latitude. If Ramadan falls during periods where longer
daylight hours pose considerable risk, patients may instead
fast during the shorter winter days. Warmer months are
also more challenging because they can increase the risk
of dehydration and electrolyte imbalances.
Paying charity
The fidyah is a charitable contribution that is offered with
each day of missed Ramadan fasts. This is done when
making up the fast is not possible because of persistent
illness or other ongoing exempting factors throughout
the year.
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American Academy of Family American
American Family
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Physicians. For thePhysician
Physician  1
private, non-
 EDITORIALS
may tolerate subsequent fasts and where modification may
be required. Physicians should be aware of these nuances
and consider exploring them with higher-risk patients, who
should be encouraged to discuss matters with a trusted reli-
gious authority, particularly when the patient is advised not
to fast and remains hesitant to abstain from fasting.
This editorial summarizes the British Islamic Medical
Association’s Ramadan compendium’s approach for fast-
ing in patients with cardiovascular disease or epilepsy and
recommendations for mental health wellness,2 along with
public health opportunities that Ramadan affords through
lifestyle modification.
CARDIOVASCULAR DISEASE
Dehydration is common during fasting and can predispose
patients with underlying cardiovascular disease to elec-
trolyte abnormalities and fasting-associated hypotension.
Recent acute coronary syndrome (within six weeks) and any
unstable cardiovascular disease could increase the risk from
fasting because patients may still be in the process of receiv-
ing interventions, rehabilitation, or optimizing treatments.4
Care should be taken with oral medications that have a
dosing regimen that occurs during fasting hours, such as
midday, because these doses would be skipped to maintain
a valid fast. Physicians may consider switching to once- or
twice-daily regimens where appropriate. In particular, direct
oral anticoagulants and antiplatelets must be monitored
because under- or overdosing could occur if the time frame
between doses is significantly different than recommended.
EPILEPSY
Because patients with epilepsy are sensitive to changes in
drug bioavailability, fasting may increase the risk of seizure.
Medications should be reviewed well before Ramadan to
establish adequate, timely control ahead of fasting, espe-
cially if therapy needs to be changed. Published guidance
on medication optimization is available.5 Circadian disrup-
tion is commonly experienced during Ramadan because of
predawn meals that begin the fast and late-night prayers.
Fatigue and disruption in sleep are seizure triggers, and
promoting sleep hygiene is vital.
MENTAL HEALTH WELLNESS
Ramadan is a highly social experience with communal
activities taking place throughout the month. Many Mus-
lims report improvements in their mental health during this
month. However, for some unable or unwilling to fast during
Ramadan, feelings of guilt and exclusion can affect their
experience, leading to isolation and worsening mental health.
Patients with bipolar disorders are sensitive to circadian
disruptions and should take extra care, especially if they
have had a recent relapse.2 Patients taking lithium are at
higher risk because of fasting-related electrolyte imbalances
2  American Family
Family Physician
Physician www.aafp.org/afp
and a narrow therapeutic window. Those who lack mental
capacity due to either an acute episode or from chronic
mental health disorders are religiously exempt from fast-
ing.6 Because of the focus on food, patients with active eat-
ing disorders are also at very high risk, although there is
significant variability of disease expression in Ramadan.
Lifestyle Modification
Ramadan involves a change in schedule for an entire month
and therefore presents an opportunity to discuss health-
ier lifestyle choices with patients. Smoking breaks the fast,
and cessation strategies should be promoted, such as using
transdermal nicotine replacement patches. Targeted weight
management advice may also yield results as individuals are
driven to revise meals and routines.
Physical activity is best undertaken during nonfasting
hours or close to the end of the fast, with monitoring of
hydration and caloric intake during meals, and progres-
sively increasing exercise intensity. Athletes can refer to
specialist guidance that outlines dietary plans and training
routines that can also be used by healthy nonathletes.7
Conclusion
Ramadan is an important month for many Muslims. Patients
value a shared decision-making process that individualizes
risk and choice. By using some of the principles outlined in
this editorial, physicians can help patients with chronic con-
ditions safely manage Ramadan fasting and use the motiva-
tion around Ramadan to adopt healthier lifestyles.
Address correspondence to Salman Waqar, MRCGP, at s.waqar@​
imperial.ac.uk. Reprints are not available from the authors.
Author disclosure:​No relevant financial relationships.
References
1. International Diabetes Federation;​Diabetes and Ramadan Interna-
tional Alliance (IDF-DAR). Diabetes and Ramadan:​practical guidelines
2021. Accessed November 29, 2022. https://​w ww.daralliance.org/
daralliance/idf-dar-practical-guidelines-2021/
2. British Islamic Medical Association (BIMA). Ramadan compendium.
December 11, 2021. Accessed November 29, 2022. https://​britishima.
org/ramadan/compendium/
3. Waqar S, Ghouri N. Managing Ramadan queries in COVID-19. BJGP
Open. 2020;​4(2):​bjgpopen20X101097.
4. Akhtar AM, Ghouri N, Chahal CAA, et al. Ramadan fasting:​recommen-
dations for patients with cardiovascular disease. Heart. 2022;​108(4):​
258-265.
5. Mahmood A, Abbasi HN, Ghouri N, et al. Managing epilepsy in Rama-
dan:​guidance for healthcare providers and patients. Epilepsy Behav.
2020;​1 11:​107117.
6. Furqan Z, Awaad R, Kurdyak P, et al. Considerations for clinicians treat-
ing Muslim patients with psychiatric disorders during Ramadan. Lancet
Psychiatry. 2019;​6(7):​556-557.
7. Aspetar. Aspetar clinical guideline:​Ramadan fasting and exercise for
healthy individuals. April 29, 2021. Accessed November 29, 2022.​
ht tps:// ​ w w w.aspetar.com/A spetarFILEUPLOAD/UploadCenter/​
637556398121737163_ Aspetar%20clinical%20guideline%20for%20
Ramadan.pdf ■
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